Effectiveness of physiotherapy exercise after knee arthroplasty for osteoarthritis: systematic review and meta-analysis of randomised controlled trials

BMJ 2007; 335 doi: (Published 18 October 2007) Cite this as: BMJ 2007;335:812
  1. Catherine J Minns Lowe, research fellow1,
  2. Karen L Barker, director2,
  3. Michael Dewey, special lecturer3,
  4. Catherine M Sackley, professor of physiotherapy research1
  1. 1Department of Primary Care and General Practice, University of Birmingham
  2. 2Physiotherapy Research Unit, Nuffield Orthopaedic Hospital NHS Trust, Oxford
  3. 3School of Community Health Sciences, University of Nottingham
  1. Correspondence to: C J Minns Lowe, Physiotherapy Research Unit, Nuffield Orthopaedic Centre NHS Trust, Oxford OX3 7LD catherine.minnslowe{at}
  • Accepted 8 August 2007


Objective To evaluate the effectiveness of physiotherapy exercise after elective primary total knee arthroplasty in patients with osteoarthritis.

Design Systematic review.

Data sources Database searches: AMED, CINAHL, Embase, King's Fund, Medline, Cochrane library (Cochrane reviews, Cochrane central register of controlled trials, DARE), PEDro, Department of Health national research register. Hand searches: Physiotherapy, Physical Therapy, Journal of Bone and Joint Surgery (Britain) Conference Proceedings.

Review methods Randomised controlled trials were reviewed if they included a physiotherapy exercise intervention compared with usual or standard physiotherapy care, or compared two types of exercise physiotherapy interventions meeting the review criteria, after discharge from hospital after elective primary total knee arthroplasty for osteoarthritis.

Outcome measures Functional activities of daily living, walking, quality of life, muscle strength, and range of motion in the knee joint. Trial quality was extensively evaluated. Narrative synthesis plus meta-analyses with fixed effect models, weighted mean differences, standardised effect sizes, and tests for heterogeneity.

Results Six trials were identified, five of which were suitable for inclusion in meta-analyses. There was a small to moderate standardised effect size (0.33, 95% confidence interval 0.07 to 0.58) in favour of functional exercise for function three to four months postoperatively. There were also small to moderate weighted mean differences of 2.9 (0.61 to 5.2) for range of joint motion and 1.66 (−1 to 4.3) for quality of life in favour of functional exercise three to four months postoperatively. Benefits of treatment were no longer evident at one year.

Conclusions Interventions including physiotherapy functional exercises after discharge result in short term benefit after elective primary total knee arthroplasty. Effect sizes are small to moderate, with no long term benefit.


  • We thank Robert Bourne, David Beverland, P Codine, Helen Frost, Patricia Humphreys, John Kramer, and Brian Mockford for providing additional data for the review. Mike Clarke and students on the “Systematic Reviews” Module, May 2005, University of Oxford Department for Continuing Education, commented on the design of the review during its planning.

  • Contributors: CJML designed the review, undertook the review searches, screened trials for eligibility, assessed the quality of the trials, assisted with data analysis, and drafted the paper. She is guarantor. KLB supervised the review, assessed the quality of trials, and reviewed the draft paper. MD designed and undertook the meta-analyses for the review and reviewed the draft paper. CMS supervised the review, screened trials for eligibility, and cowrote the paper.

  • Funding: CJML is funded by a nursing and allied health professional researcher development award from the Department of Health and NHS research and development. CMS is funded by a primary care career scientist award from the Department of Health and NHS research and development.

  • Competing interests: None declared.

  • Ethical approval: Oxford local research ethics committee (AQREC No A03.018).

    Provenance and peer review: Not commissioned; peer reviewed.

  • Accepted 8 August 2007
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